What is the best next step in managing heavy menstrual bleeding in a 32-year-old nulliparous woman with multiple submucosal fibroids and a thickened endometrium?

From the Guidelines

The best next step in management of this patient's heavy menstrual bleeding is to perform a hysteroscopic myomectomy, as it is a minimally invasive procedure that can effectively remove submucosal fibroids and reduce menstrual bleeding while preserving fertility. This approach is supported by the most recent evidence from the American College of Radiology, which states that hysteroscopic myomectomy is indicated in patients with submucosal fibroids desiring uterus preservation 1. The procedure has been shown to improve symptom scores and quality of life, with equivalent results to other surgical approaches at 2 to 3 months 1. Given the patient's plans for future pregnancy and her current symptoms of heavy menstrual bleeding, hysteroscopic myomectomy is a suitable option. Some key points to consider include:

• The patient's submucosal fibroids are likely causing her heavy bleeding by distorting the endometrial cavity.
• Hysteroscopic myomectomy is a minimally invasive procedure with shorter hospitalization and faster return to usual activities compared to laparoscopic or open myomectomy 1.
• Medical management options, such as tranexamic acid or hormonal contraceptives, may not be as effective in reducing bleeding symptoms in patients with submucosal fibroids, and may have contraindications or side effects, such as the patient's history of migraines with aura 1.
• The patient's desire for future pregnancy makes hysteroscopic myomectomy a more suitable option, as it preserves fertility and allows for quick recovery.

From the FDA Drug Label

The FDA drug label does not answer the question.

From the Research

Patient Evaluation

The patient presents with heavy menstrual bleeding, defined as excessive menstrual blood loss >80 mL per cycle, which interferes with her physical, emotional, social wellbeing, and quality of life 2. The patient's symptoms, including 6 days of heavy bleeding and frequent bleeding through clothes, indicate a significant impact on her daily life.

Underlying Cause

The patient's pelvic examination and transvaginal ultrasound reveal an enlarged uterus with multiple submucosal fibroids, which are likely contributing to her heavy menstrual bleeding 3. The presence of fibroids is a common cause of heavy menstrual bleeding in women of reproductive age.

Management Options

The management of heavy menstrual bleeding depends on the underlying cause and the woman's preference and fertility wishes 2. Medical therapies, such as hormonal treatments, including levonorgestrel-releasing intrauterine system (LNG-IUS) and combined hormonal contraceptives, can be effective in reducing menstrual blood loss 2, 3. Additionally, haemostatic therapies, such as tranexamic acid, can be used to reduce menstrual blood loss 3, 4.

Next Steps

Given the patient's desire to become pregnant in the next year, medical therapies that do not affect fertility, such as tranexamic acid, may be considered as a first-line treatment 4, 5. However, the patient's underlying fibroids may require further evaluation and treatment, such as ulipristal acetate, which has demonstrated efficacy in reducing menstrual blood loss in women with uterine fibroids 2.

Key Considerations

• The patient's migraines with aura should be considered when selecting a treatment option, as some hormonal therapies may exacerbate migraine symptoms.
• The patient's BMI and blood pressure should be monitored, as they may impact her overall health and treatment outcomes.
• The patient's desire to become pregnant in the next year should be taken into account when selecting a treatment option, and fertility-sparing treatments should be considered whenever possible.